OB POSTPARTUM NCLEX EXAM
QUESTIONS WITH 100%
CORRECT ANSWERS
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma.
The nurse includes which specific intervention in the plan during the first 12 hours
following the delivery of this client?
A) Assess vital signs every 4 hours
B) Inform health care provider of assessment findings
C) Measure fundal height every 4 hours
D) Prepare an ice pack for application to the area. - Answer-D) Prepare an ice pack for
application to the area.
Rationale: Application of ice will reduce swelling caused by hematoma formation in the
vulvar area. The other options are not interventions that are specific to the plan of care
for a client with a small vulvar hematoma.
A new mother received epidural anesthesia during labor and had a forceps delivery
after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20
points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute.
The client is anxious and restless. On further assessment, a vulvar hematoma is
verified. After notifying the health care provider, the nurse immediately plans to:
A) Monitor fundal height
B) Apply perineal pressure
C) Prepare the client for surgery.
D) Reassure the client - Answer-C) Prepare the client for surgery.
Rationale: The use of an epidural, prolonged second stage labor and forceps delivery
are predisposing factors for hematoma formation, and a collection of up to 500 ml of
blood can occur in the vaginal area. Although the other options may be implemented,
the immediate action would be to prepare the client for surgery to stop the bleeding.
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of
the following signs, if noted in the mother, would be an early sign of excessive blood
loss?
A) A temperature of 100.4*F
B) An increase in the pulse from 88 to 102 BPM
C) An increase in the respiratory rate from 18 to 22 breaths per minute
,D) A blood pressure change from 130/88 to 124/80 mm Hg - Answer-B) An increase in
the pulse from 88 to 102 BPM
Rationale: During the 4th stage of labor, the maternal blood pressure, pulse, and
respiration should be checked every 15 minutes during the first hour. A rising pulse is
an early sign of excessive blood loss because the heart pumps faster to compensate for
reduced blood volume. The blood pressure will fall as the blood volume diminishes, but
a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise
in temperature is normal. The respiratory rate is increased slightly.
A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus feels
soft and boggy. Which of the following nursing interventions would be most appropriate
initially?
A) Massage the fundus until it is firm
B) Elevate the mothers legs
C) Push on the uterus to assist in expressing clots
D) Encourage the mother to void - Answer-A) Massage the fundus until it is firm
Rationale: If the uterus is not contracted firmly, the first intervention is to massage the
fundus until it is firm and to express clots that may have accumulated in the uterus.
Pushing on an uncontracted uterus can invert the uterus and cause massive
hemorrhage. Elevating the client's legs and encouraging the client to void will not assist
in managing uterine atony. If the uterus does not remain contracted as a result of the
uterine massage, the problem may be distended bladder and the nurse should assist
the mother to urinate, but this would not be the initial action.
A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section.
The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which
of the following signs or symptoms would the nurse note if superficial venous
thrombosis were present?
A) Paleness of the calf area
B) Enlarged, hardened veins
C) Coolness of the calf area
D) Palpable dorsalis pedis pulses - Answer-B) Enlarged, hardened veins
Rationale: Thrombosis of the superficial veins is usually accompanied by signs and
symptoms of inflammation. These include swelling of the involved extremity and
redness, tenderness, and warmth.
A nurse is providing instructions to a mother who has been diagnosed with mastitis.
Which of the following statements if made by the mother indicates a need for further
teaching?
A) "I need to take antibiotics, and I should begin to feel better in 24-48 hours."
B) "I can use analgesics to assist in alleviating some of the discomfort."
C) "I need to wear a supportive bra to relieve the discomfort."
, D) "I need to stop breastfeeding until this condition resolves." - Answer-D) "I need to
stop breastfeeding until this condition resolves."
Rationale: In most cases, the mother can continue to breastfeed with both breasts. If the
affected breast is too sore, the mother can pump the breast gently. Regular emptying of
the breast is important to prevent abscess formation. Antibiotic therapy assists in
resolving the mastitis within 24-48 hours. Additional supportive measures include ice
packs, breast supports, and analgesics.
A PP client is being treated for DVT. The nurse understands that the client's response to
treatment will be evaluated by regularly assessing the client for:
A) Dysuria, ecchymosis, and vertigo
B) Epistaxis, hematuria, and dysuria
C) Hematuria, ecchymosis, and epistaxis
D) Hematuria, ecchymosis, and vertigo - Answer-C) Hematuria, ecchymosis, and
epistaxis
Rationale: The treatment for DVT is anticoagulant therapy. The nurse assesses for
bleeding, which is an adverse effect of anticoagulants. This includes hematuria,
ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with
bleeding.
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that
the client has cool, clammy skin and is restless and excessively thirsty. The nurse
prepares immediately to:
A) Assess for hypovolemia and notify the health care provider
B) Begin hourly pad counts and reassure the client
C) Begin fundal massage and start oxygen by mask
D) Elevate the head of the bed and assess vital signs - Answer-A) Assess for
hypovolemia and notify the health care provider
Rationale: Symptoms of hypovolemia include cool, clammy, pale skin, sensations of
anxiety or impending doom, restlessness, and thirst. When these symptoms are
present, the nurse should further assess for hypovolemia and notify the health care
provider.
A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm
but that bleeding is excessive. The initial nursing action would be which of the
following?
A) Massage the fundus
B) Place the mother in the Trendelenburg's position
C) Notify the physician
D) Record the findings - Answer-C) Notify the physician
QUESTIONS WITH 100%
CORRECT ANSWERS
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma.
The nurse includes which specific intervention in the plan during the first 12 hours
following the delivery of this client?
A) Assess vital signs every 4 hours
B) Inform health care provider of assessment findings
C) Measure fundal height every 4 hours
D) Prepare an ice pack for application to the area. - Answer-D) Prepare an ice pack for
application to the area.
Rationale: Application of ice will reduce swelling caused by hematoma formation in the
vulvar area. The other options are not interventions that are specific to the plan of care
for a client with a small vulvar hematoma.
A new mother received epidural anesthesia during labor and had a forceps delivery
after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20
points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute.
The client is anxious and restless. On further assessment, a vulvar hematoma is
verified. After notifying the health care provider, the nurse immediately plans to:
A) Monitor fundal height
B) Apply perineal pressure
C) Prepare the client for surgery.
D) Reassure the client - Answer-C) Prepare the client for surgery.
Rationale: The use of an epidural, prolonged second stage labor and forceps delivery
are predisposing factors for hematoma formation, and a collection of up to 500 ml of
blood can occur in the vaginal area. Although the other options may be implemented,
the immediate action would be to prepare the client for surgery to stop the bleeding.
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of
the following signs, if noted in the mother, would be an early sign of excessive blood
loss?
A) A temperature of 100.4*F
B) An increase in the pulse from 88 to 102 BPM
C) An increase in the respiratory rate from 18 to 22 breaths per minute
,D) A blood pressure change from 130/88 to 124/80 mm Hg - Answer-B) An increase in
the pulse from 88 to 102 BPM
Rationale: During the 4th stage of labor, the maternal blood pressure, pulse, and
respiration should be checked every 15 minutes during the first hour. A rising pulse is
an early sign of excessive blood loss because the heart pumps faster to compensate for
reduced blood volume. The blood pressure will fall as the blood volume diminishes, but
a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise
in temperature is normal. The respiratory rate is increased slightly.
A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus feels
soft and boggy. Which of the following nursing interventions would be most appropriate
initially?
A) Massage the fundus until it is firm
B) Elevate the mothers legs
C) Push on the uterus to assist in expressing clots
D) Encourage the mother to void - Answer-A) Massage the fundus until it is firm
Rationale: If the uterus is not contracted firmly, the first intervention is to massage the
fundus until it is firm and to express clots that may have accumulated in the uterus.
Pushing on an uncontracted uterus can invert the uterus and cause massive
hemorrhage. Elevating the client's legs and encouraging the client to void will not assist
in managing uterine atony. If the uterus does not remain contracted as a result of the
uterine massage, the problem may be distended bladder and the nurse should assist
the mother to urinate, but this would not be the initial action.
A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section.
The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which
of the following signs or symptoms would the nurse note if superficial venous
thrombosis were present?
A) Paleness of the calf area
B) Enlarged, hardened veins
C) Coolness of the calf area
D) Palpable dorsalis pedis pulses - Answer-B) Enlarged, hardened veins
Rationale: Thrombosis of the superficial veins is usually accompanied by signs and
symptoms of inflammation. These include swelling of the involved extremity and
redness, tenderness, and warmth.
A nurse is providing instructions to a mother who has been diagnosed with mastitis.
Which of the following statements if made by the mother indicates a need for further
teaching?
A) "I need to take antibiotics, and I should begin to feel better in 24-48 hours."
B) "I can use analgesics to assist in alleviating some of the discomfort."
C) "I need to wear a supportive bra to relieve the discomfort."
, D) "I need to stop breastfeeding until this condition resolves." - Answer-D) "I need to
stop breastfeeding until this condition resolves."
Rationale: In most cases, the mother can continue to breastfeed with both breasts. If the
affected breast is too sore, the mother can pump the breast gently. Regular emptying of
the breast is important to prevent abscess formation. Antibiotic therapy assists in
resolving the mastitis within 24-48 hours. Additional supportive measures include ice
packs, breast supports, and analgesics.
A PP client is being treated for DVT. The nurse understands that the client's response to
treatment will be evaluated by regularly assessing the client for:
A) Dysuria, ecchymosis, and vertigo
B) Epistaxis, hematuria, and dysuria
C) Hematuria, ecchymosis, and epistaxis
D) Hematuria, ecchymosis, and vertigo - Answer-C) Hematuria, ecchymosis, and
epistaxis
Rationale: The treatment for DVT is anticoagulant therapy. The nurse assesses for
bleeding, which is an adverse effect of anticoagulants. This includes hematuria,
ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with
bleeding.
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that
the client has cool, clammy skin and is restless and excessively thirsty. The nurse
prepares immediately to:
A) Assess for hypovolemia and notify the health care provider
B) Begin hourly pad counts and reassure the client
C) Begin fundal massage and start oxygen by mask
D) Elevate the head of the bed and assess vital signs - Answer-A) Assess for
hypovolemia and notify the health care provider
Rationale: Symptoms of hypovolemia include cool, clammy, pale skin, sensations of
anxiety or impending doom, restlessness, and thirst. When these symptoms are
present, the nurse should further assess for hypovolemia and notify the health care
provider.
A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm
but that bleeding is excessive. The initial nursing action would be which of the
following?
A) Massage the fundus
B) Place the mother in the Trendelenburg's position
C) Notify the physician
D) Record the findings - Answer-C) Notify the physician
